Inspection Summary

Overall summary & rating

Our rating of these services stayed the same. We rated them as inadequate because:

Not all issues highlighted in the section 29A warning notices and previous inspections had been addressed in the emergency department (ED).

The department remained severely crowded and measures previously identified to prevent this had produced little significant improvement. The patient safety matrix did not contain guidance about what to do in these circumstances.

Routine use of the corridor to care for patients over long periods of time was previously highlighted as a major patient safety concern.

There were delays of up to six hours for specialist doctors to respond to patients who had been referred to them for treatment.

Compliance with mandatory training did not meet the trust target of 90% in the majority of modules. Not all nursing staff had received basic or intermediate life support training.

Staff compliance with safeguarding children’s training did not meet national recommendations.

There was no privacy and little confidentiality for patients waiting on trolleys in the corridor. ED staff were frustrated about this situation and were as discrete and considerate as possible. Patients were moved to a more private cubicle when intimate care was needed.

Many patients could not access the service when they needed it.

Patients spent longer in this ED than at other trusts in England. The monthly total time spent in ED for all patients was consistently worse than the England average from November 2016 to September 2017. During our inspection patients who needed to be admitted to a ward were spending up to 20 hours in the department.

Emergency departments in England are expected to ensure that 95% of their patients are admitted, transferred or discharged within four hours of arrival. The standard had not been met in any month at the Worcestershire Royal Hospital since November 2013. From November 2016 to October 2017, 62.8% of patients were admitted, transferred or discharged within four hours of arrival.

There was no documented local strategy for the emergency department.

Risk management processes remained an area of concern. The ED did not have its own risk register. It was unclear how staff used all risk documents effectively to manage and mitigate risks.

Medicine ward nurse staffing levels were frequently below the nurse establishment particularly at night. Ward managers escalated any concerns with patient acuity and staffing to arrange additional support where possible.

Escalation areas, such as the trauma assessment unit, were not always fully equipped to meet the demands of inpatient care.

The stroke service did not provide a seven day transient ischaemic attack clinic in line with national guidance.

There was a high number of patient bed moves between 10pm and 8am.

Patient complaints were not responded to within the 25 days outlined in trust policy.

However:

Staff cared for patients with compassion.

Adult nurse staffing levels within the department meet national guidance. Since November 2017, there were sufficient registered children’s nurses in post to ensure that the ED had at least one registered children’s nurse on duty per shift in line with national guidelines for safer staffing for children in EDs.

Staff kept appropriate records of patients’ care and treatment.

Equipment, clinical waste and specimens were stored, labelled and handled appropriately throughout the ED.

Patient risk assessments had been completed correctly and in a timely manner.

The ED provided care and treatment that was based on national guidance.

Reasonable adjustments had been made for patients with dementia, a learning disability, gender and cultural needs.

Medicines were stored appropriately with processes in place for monitoring usage and safe storage. Medicines were prescribed and administered in line with guidance and patients received the right dose at the right time.

There were robust processes in place for the recording, escalation and sharing of learning from incidents.

Patient’s pain was assessed and monitored with processes in place to offer appropriate pain control and refer for additional support when necessary.

Capacity and flow had been reviewed with ward managers taking the responsibility for pulling patients to speciality wards to ensure that patients were located in the correct environment for their clinical condition.

Staff felt supported, able to challenge, and felt listened too.

The service used divisional dashboards to review and monitor performance. This was discussed locally within the division and escalated to the trust board for oversight of performance.

Well-led

Inspection report

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Checks on specific services

Maternity and gynaecology

Updated 8 August 2017

We carried out a focused inspection to review concerns found during our previous comprehensive inspection on 22 to 25 November 2016. We inspected parts of four of the five key questions but did not rate them. We found significant improvements had not been made in these areas:

Although perinatal mortality and morbidity meetings were minuted, there was no evidence that action was taken to address learning from case reviews. We were not assured an effective system was in place to ensure learning from perinatal mortality and morbidity meetings was shared, and actions were taken to improve the safety and quality of patient care.

Staff did not consistently follow trust processes for storing medicines at the recommended temperatures, despite there being policies in place.

We also found other areas of concern:

There was no system in place to ensure medicines stored in the emergency gynaecology assessment unit were safe for patient use. Immediate action was taken by the trust once we raised this as a concern.

Training data showed that 86% of midwifery staff and 53% of medical staff had completed safeguarding children level three training. This was an improvement from our previous inspection. However, compliance was still below the trust target of 90%, particularly with medical staff.

The waiting room and toilet facilities for patients attending the emergency gynaecology assessment unit were mixed sex, as these were shared with the respiratory outpatient clinic. Furthermore, this assessment unit did not have appropriate facilities such as bathrooms, to facilitate personal care for patients who had to stay overnight at times of increased bed pressures.

However, we observed improvements for the following:

Standards of cleanliness and hygiene were well maintained. Staff adhered to infection control and prevention guidance.

Effective systems had been introduced to ensure emergency equipment was checked daily. Equipment was well maintained and had been safety tested to ensure it was fit for purpose.

The hospital did not have a dedicated gynaecology inpatient ward. This meant some patients stayed overnight in the outpatient emergency gynaecology assessment unit and were nursed in medical wards. However, the trust had put processes in place to ensure patients were cared for in environments that were suitable for their needs.

The number of staff who had completed Mental Capacity Act and Deprivation of Liberty Safeguards training had improved.

Daily ward rounds by a gynaecology consultant and nurse were carried out to ensure gynaecology patients were appropriately reviewed and managed, regardless of location within the trust.

Staff caring for gynaecology patients on Beech B1 ward had received training on bereavement care, including early pregnancy loss and the management of miscarriage.

Risks identified were reviewed regularly with mitigation and assurances in place. Staff were aware of the risks and the trust board had oversight of the main risks within the service.

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Medical care (including older people’s care)

Our overall rating of this service improved. We rated it as requires improvement because:

Ward nurse staffing levels were frequently below the nurse establishment particularly at night. Ward managers escalated any concerns with patient acuity and staffing to arrange additional support where possible.

Staff skills in the Trauma Assessment Unit and Silver Oncology Unit did not necessarily meet the requirements for the patients cared for within these areas. There were plans in place to address this in the Silver Oncology Unit.

Senior medical cover, at night was minimal, with one registrar responsible for all medical inpatient areas and acute admissions.

Mandatory training figures did not meet the trust target of 90%. This included poor compliance with safeguarding children and vulnerable adults training in nurses and doctors.

Appraisal rates for medical and nursing staff did not meet the trust target of 90%.

Escalation areas, such as the trauma assessment unit, were not always fully equipped to meet the demands of inpatient care.

There was variable performance in national audit outcomes. For example, the Hospital Standardised Mortality Ratio and Summary Hospital-level Mortality Indicator was worse than expected.

The upper gastrointestinal endoscopy performance was worse than expected and the Joint Advisory Group accreditation had been deferred following a recent inspection of endoscopy services.

The stroke service did not provide a seven day transient ischaemic attack clinic in line with national guidance.

The service performed worse than the national average in the dementia care audit.

The service reported a high number of patient bed moves between 10pm and 8am.

Patient complaints were not responded to within the 25 days outlined in trust policy.

There were variable accounts of clinical leadership, with some reports that specialities were disjointed due to differing consultant opinions. Staff reported that this affected cross-site working.

There were pockets across the service where changes were not established.

However, we also found that:

Equipment was checked annually for fitness for purpose.

Patients were assessed on admission and at regular intervals using nationally recognised assessment tools. Patient records were up to date, clearly written and held securely.

The service had introduced a safer staffing application, which was used to monitor staffing across the hospital, enabling senior staff to identify areas of pressure.

Medicines were stored appropriately with processes in place for monitoring usage and safe storage. Medicines were prescribed and administered in line with guidance and patients received the right dose at the right time.

There were robust processes in place for the recording, escalation and sharing of learning from incidents.

Policies and processes used were based on national guidance.

Patient’s pain was assessed and monitored with processes in place to offer appropriate pain control and refer for additional support when necessary.

Patients were treated with compassion, respect with dignity maintained at all times.

Capacity and flow had been reviewed with ward managers taking the responsibility for pulling patients to speciality wards to ensure that patients were located in the correct environment for their clinical condition.

Leadership had been reconstructed and staff felt that this had improved the progression of the service.

Staff felt supported, able to challenge, and felt listened too.

The service used divisional dashboards to review and monitor performance. This was discussed locally within the division and escalated to the trust board for oversight of performance.

The service used a risk register to identify risks to the service and any mitigating actions taken to reduce risk.

Inspection report

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Urgent and emergency services (A&E)

Our overall rating of this service stayed the same. We rated it as inadequate because:

Not all issues highlighted in the section 29A warning notices and previous inspections had been addressed in the emergency department (ED).

The department remained severely crowded and measures previously identified to prevent this had produced little significant improvement. The patient safety matrix did not contain guidance about what to do in these circumstances.

Routine use of the corridor to care for patients over long periods of time was previously highlighted as a major patient safety concern.

There were delays of up to six hours for specialist doctors to respond to patients who had been referred to them for treatment.

Compliance with mandatory training did not meet the trust target of 90% in the majority of modules. Not all nursing staff had received basic or intermediate life support training.

Staff compliance with safeguarding children’s training did not meet national recommendations.

Results from the RCEM audit on consultant sign-off of records were not as good as other departments in England.

The rate of patients re-attending the ED did not meet the national standard.

There was no privacy and little confidentiality for patients waiting on trolleys in the corridor. ED staff were frustrated about this situation and were as discrete and considerate as possible. However, patients were moved to a more private cubicle when intimate care was needed.

Many patients could not access the service when they needed it.

Patients spent longer in this ED than at other trusts in England. The monthly total time spent in ED for all patients was consistently worse than the England average from November 2016 to September 2017. During our inspection patients who needed to be admitted to a ward were spending up to 20 hours in the department.

Emergency departments in England are expected to ensure that 95% of their patients are admitted, transferred or discharged within four hours of arrival. The standard had not been met in any month at the Worcestershire Royal Hospital since November 2013. From November 2016 to October 2017, 62.8% of patients were admitted, transferred or discharged within four hours of arrival.

Patient flow through the hospital had improved slightly since the inspection in November 2016 but performance remained inconsistent and was significantly worse than the England average.

Complaints were not responded to in a timely way.

There was no documented local strategy for the department. A divisional strategy was being developed at the time of inspection; however, this had not been finalised or implemented.

Risk management processes remained an area of concern. The ED did not have its own risk register. It was unclear how staff used all risk documents effectively to manage and mitigate risks.

We asked for minutes of the last two ED clinical governance meetings but none were sent for Worcestershire Royal Hospital. We therefore could not be assured that the governance arrangements supported the delivery of good quality patient care.

However:

Staff cared for patients with compassion.

Adult nurse staffing levels within the department meet national guidance. Adult nurse staffing levels within the department meet national guidance. Since November 2017, there were sufficient registered children’s nurses in post to ensure that the ED had at least one registered children’s nurse on duty per shift in line with national guidelines for safer staffing for children in EDs.

Staff kept appropriate records of patients’ care and treatment.

Equipment, clinical waste and specimens were stored, labelled and handled appropriately throughout the ED.

Patient risk assessments had been completed correctly and in a timely manner.

Hand hygiene best practice was followed to prevent the spread of infection.

Patients were assessed within 15 minutes of arrival.

Medicines were stored in line with trust policy.

Learning from incidents were implemented, reviewed or shared.

The ED provided care and treatment that was based on national guidance.

Results of two of the three Royal College of Emergency Medicine (RCEM) audits were as good as, or better than, other departments in England.

There was a structured competency framework for nurses that was aligned with the Royal College of Nursing national curriculum for emergency nurses. Records showed that all ED nurses had received an appraisal in the last year.

Reasonable adjustments had been made for patients with dementia, a learning disability, gender and cultural needs.

The local leadership team were highly visible in the department and often worked clinically to support their staff.

Inspection report

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Surgery

Updated 8 August 2017

We carried out this focused I and inspected four of the five key questions but we did not rate them. This was a focused inspection to review concerns found during our previous comprehensive inspection in November 2016 and therefore we did not inspect every aspect of each key question. We found significant improvements had not been made in these areas:

Venous thromboembolism risk assessments (VTE) and 24 hour reassessments were not completed in line with national guidance.

Some staff did not clean their hands before or after patient contact and some staff wore personal protective equipment inappropriately.

Fridge temperatures for the storage of medicines exceeded recommended ranges in two areas visited

Anticoagulation medicines had not always been administered as prescribed.

We also found other areas of concern on this inspection :

Some patients were prescribed inappropriate doses of anticoagulation medication without regard to their weight.

Some wards did not display their planned staff on duty only their actual staff on duty.

Visitors to wards could see patient identification details on electronic white boards.

Senior leaders were aware of the trust’s failure to follow national guidance in relation to venous thromboembolism risk assessments (VTE) and hand hygiene. However, we saw examples throughout the service where compliance with trust and national guidance had not significantly improved.

When risks had been escalated, there was a lack of follow up and resolution. Effective action following the reporting of high fridge temperatures for storage of medicines was not evident.

However, we observed improvements for the following:

All staff we saw in clinical areas had ‘arms bare below elbows’.

There were fewer reported staff shortages and shortfalls were escalated and risk assessed so patients’ needs were met.

The hospital had implemented a new quality dashboard. The dashboard provided monthly quality data for all wards and clinical areas.

Inspection report

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Intensive/critical care

Requires improvement

Updated 20 June 2017

We rated critical care as requiring improvement because:

We found that clinical incidents were not always categorised accurately or reported externally. We saw evidence that staff remained confused as to what constituted a near miss incident and reported incidents as a near miss when patients were placed at risk.

Outside of critical care, staff felt pressurised and unsupported. Nursing staff felt that patient care was not a priority to the trust.

The executive team were not visible across the organisation and staff felt that the lack of a permanent executive team affected progress.

Nursing records within the high dependency units were not always contemporaneous, with data entries being completed at the end of clinical shifts and not when events occurred.

The clinical environment for the critical care and high dependency units did not meet all the recommendations set out in the Health Building Note 04-02 Critical care units’ standards. This included limited washing and toileting facilities for mobile patients on the critical care and high dependency units.

Staff did not always adhere to infection control and prevention practices.

Consultants were responsible for the management of children admitted as an emergency until transfer to a children’s specialist hospital was arranged.

Patients on the high dependency units who were categorised as level two due to arterial line being in situ were not provided with additional screens or privacy when placed in beds opposite a member of the opposite sex.

We saw that venous thromboembolism assessments were not always completed in line with recommendations, with the repeat assessment after 24 hours of admission missing.

Mandatory training compliance did not always meet the trust target. High dependency staff had not completed critical care handbooks at the time of inspection, although these were in progress.

Medical consultants were not always allocated to the care of patients following discharge from critical care, which affected patient follow up after discharge.

There was a limited follow up service for patients discharged from critical care with no provision of a formal medical lead clinic.

However:

Critical care staff completed a daily safety brief where they discussed any incidents or complaints and identified learning. Learning was also shared across the service at team meetings.

Appropriate staff regularly reviewed patients. Medical teams reviewed patients a minimum of twice daily. The critical care outreach service assisted with the monitoring and treatment planning of sick patients across the trust, providing local support for teaching and monitoring of compliance in trust wide deteriorating patient audits.

Critical care were able to ensure safety across the county wide service by transferring skilled staff to assist with the management of patient care according to need.

The service had implemented a weekly multidisciplinary team meeting to review patient’s rehabilitation needs.

Critical care used evidence based patient pathways, policies and protocols to provide care.

Trust data published by the Intensive Care National Audit and Research Centre detailed that the service performed in line with similar sized organisations and as expected.

The service provided a seven-day service with access to specialists, such as dietetics and pain specialists, for additional treatments or advice. Specialist were involved with the planning of treatments and participated in multidisciplinary team meetings.

The service had a robust training programme for staff that included the use of a competency handbook, local training support from the practice development nurses and scenario based training.

Patients and their relatives were treated in a compassionate, respectful manner. Staff provided privacy for relatives and patients. Patients and their relatives were supported during their stay within critical care with staff offering opportunities to discuss care and treatment.

There were additional facilities within the critical care unit, which enabled patient’s relatives or loved ones to stay on site. There were also facilities for those requiring additional support for aspects such as learning disabilities, translation services.

Staff and relatives used patient diaries to record events. These helped patients understand what had happened whilst they were sedated.

There were systems in place to address formal and non-formal complaints. The most relevant persons completed investigations and responses and learning shared amongst the team though open discussion and team meetings.

Critical care had a vision of the service, which reflected the trust core values. This included the plans to centralise critical care services and build a high dependency unit.

The service had a robust governance structure and cascaded service performance data to the trust board and to staff on the units.

Local leaders were reported as being supportive, accessible and approachable.

Inspection report

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Services for children & young people

Updated 8 August 2017

We carried out a focused inspection to review concerns found during our previous comprehensive inspection in November 2016. We inspected parts of four of the five key questions (safe, effective, responsive, well-led) but did not rate them. We did not inspect the caring key question. We found significant improvements had not been made in these areas:

Whilst perinatal mortality and morbidity meetings were minuted and well attended, which was an improvement since the previous inspection, there was no evidence that action was taken to address learning from patient case reviews.

Paediatric mortality and morbidity meetings were not multidisciplinary and only attended by medical staff.

Whilst some improvements were observed in completion of Patient Early Warning Scores charts, not all charts had been completed in accordance with trust policy. We also found there was not always evidence of appropriate escalation for medical review when required.

One to one care for patients with mental health needs was not consistently provided by a member of staff with appropriate training and reliance was, on occasion, placed on parents or carers.

We also found other areas of concern:

Safeguarding children’s level three training was below the trust’s target of 85% and future training sessions had been cancelled. Compliance rates for this essential training were no better or worse in April 2017 in some staff teams compared to November 2016.

The department became busy at times and staff said activity had increased since the service reconfiguration. However, there was limited monitoring of assessment and admission to inpatient areas.

The risk register had been updated to include two additional risks identified during the November 2016 inspection, but not all risks found on this inspection had been identified, assessed and recorded. For example, the increased activity in the service following the transformation process.

There was limited oversight and planning with regards to the increased activity in the service. This meant that service leaders were not in a position to understand current and future performance and to be able to drive improvements for better patient outcomes.

However, we observed improvements for the following:

Paediatric mortality and morbidity meetings for paediatrics were now held and minuted.

Infection control protocols were followed.

There were appropriate arrangements in place for management of medicines, which included their safe storage.

All patients admitted to the ward because of an episode of self-harm or attempted suicide had a risk assessment on file.

The majority of staff had been competency assessed in medical devices used to help patients breathe more easily.

Inspection report

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End of life care

Staff understood their responsibilities to raise concerns and to record safety incidents. Incidents relating to end of life care were reviewed by the lead nurse for specialist palliative care.

There was good identification of patients at risk of deterioration and identification of patients in the last days of life.

The trust had taken action to improve the facilities in the mortuary since a previous inspection. This included replacing fridges, flooring and improving the hot water facilities.

There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. A comprehensive programme of end of life care training was available for the full range of staff within the trust.

There was good evidence of multidisciplinary working and involvement of the specialist palliative care team throughout the hospital including allied healthcare professionals as well as medical and nursing members. The specialist palliative care team provided a seven day face to face assessment service across the trust.

People were supported, treated with dignity and respect and told us they felt involved in their care. We observed staff communicating with patients and relatives in a manner than demonstrated compassion, dignity and respect.

Patients and relatives told us that the staff were caring, kind and respected their wishes. People we spoke with were complimentary about the staff and told us they felt appropriately supported.

The specialist palliative care team responded quickly to referrals and typically would see patients within a few hours if the need was urgent. The majority (92%) of patients were seen within 24 hours and there was a good balance between cancer and non-cancer referrals.

The specialist palliative care team worked proactively with the emergency department to identify patients who may benefit from palliative care input.

The trust had begun to record and audit preferred place of care at the end of life and there were clear systems in place to make improvements in this area.

The specialist palliative care team had audited complaints that had an end of life care component, identified trends and had taken action to address improvements.

There was a clear vision for the service and a draft strategy was in place, highlighting the key areas the trust were focusing on in relation to end of life care.

There was consistent promotion of the delivery of high quality person centred care and strong leadership for end of life care. Staff were consistently passionate about end of life care, positive about their roles and consistent in their belief that the quality of end of life care was good.

Innovations included close working between the specialist palliative care team and emergency department staff to identify patients at the end of life and provide specialist support. The trust was one of ten that had been chosen to participate in a quality improvement partnership with The National Council for Palliative Care and Macmillan Cancer Support.

However:

Discussions around DNACPR (do not attempt cardiopulmonary resuscitation) decisions were not always sufficiently recorded within patient’s medical records.

Feedback from relatives and staff showed there had been some delays in obtaining death certificates, although we saw that this had been discussed at the meeting of the bereavement group and we were told the lead nurse was taking the lead on addressing this issue.

Inspection report

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Outpatients

Inadequate

Updated 20 June 2017

We rated the outpatients and diagnostic imaging services as inadequate because:

There was a lack of radiation protection infrastructure.

There was inadequate review and document control of protocols for standard x-ray examinations. Some protocols were in a handwritten format with alterations made by various members of staff without apparent ratification.

Aging and unsafe equipment across the trust that was being inadequately risk rated with a lack of capital rolling replacement programmes in place.

There have been two patient safety incidents in the trust whereby patients had been physically injured by unsafe x-ray equipment.

Whilst staff were aware of their roles and responsibilities with regards to reporting patient safety incidents, incident reporting in outpatients was low and where incidents had been reported, the dissemination of lessons learnt was insufficiently robust.

The trust was failing to meet a range of benchmarked standards with regards to the time with which patients could expect to access care.

However:

Staff were dedicated and caring.

Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support.

The premises were visibly clean.

The process for keeping patients informed when clinics overran was established and well managed.

Leadership within the outpatient’s team was visible however, the management of risk was insufficiently robust and further improvements were necessary.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.